PROJECT SUMMARY AHRQ previously funded the development of Elder Tree (ET), a laptop-based eHealth system shown in a randomized trial to improve quality of life and health factors among older adults with multiple chronic conditions (MCCs) such as diabetes and hypertension. MCCs are pervasive and costly among older adults, reducing quality of life and accounting for 90% of Medicare spending. Self-management can help patients control their conditions, but these skills are rarely taught in primary care. ET provides tools and support for such self- management and addresses the frustration, discouragement, and loneliness shared by all patients with MCCs, regardless of specific disease. Despite positive results, though, many study participants did not use ET extensively, a problem for all health apps. In a separate survey, we learned that more than 60% of non-users abandoned ET because the computer was too hard to use. Voice-controlled smart technology may solve this problem. Smart speakers, used by speaking and listening rather than typing and reading, avoid barriers to use such as poor vision, tremors, and interface complexity; they have been adopted at a rate faster than the Internet or TV, especially among older adults. Smart displays enhance the system with a visual element, helping users remember content and creating access to media meant to be viewed. This application proposes to test the ability of voice-activated technology to expand the implementation and sustain the use of a proven electronic health system. Specifically, we propose to test whether older adults with MCCs will use and benefit more from ET delivered by a smart system (speaker plus display), due to ease of use, than from a laptop version of ET. The proposal has 2 aims: 1) develop the smart system platform (ET-SS) and 2) test it against laptop ET (ET-LT) in a 2-arm RCT. The trial will randomize 220 patients age 65+ with 4 or more chronic conditions to receive for 8 months either ET-LT or ET-SS. We hypothesize that: patients with ET-SS (vs. ET-LT) will have greater ET use and better quality of life in month 8. these clinical outcomes will improve: a) 30-day hospital readmissions), b) medication adherence, and c) composite score of HbA1c, mg/dL, mmHg, FEV-1, BMI, PHQ-8, FAS-GFR, and Brief Pain Inventory. the amount of ET use at 4 months will mediate the effects of ET at 8 months (i.e. greater use at 4 months=greater effects at 8 months), and negative affect and Self-Determination Theory constructs of competence, social relatedness, and intrinsic motivation will mediate the effects of ET use. ET-SS will have better outcomes for women and for patients with 6+ (vs. 4-5) chronic conditions. We, the investigators who developed ET, have conducted numerous RCTs of eHealth systems and published extensively. To our knowledge, this will be the first large RCT of a smart system as a platform to implement and disseminate a health intervention. The result could make ET more accessible and effective for older patients, improve their quality of life, and point the way to more impactful delivery of future eHealth innovations.